Influenza Vaccination Consent Form

Date

I voluntarily authorize the health care facility to use or disclose my health information for the purpose of treatment, payment, or other health care operational needs to my physician of choice, my insurance plan, and/or state or federal registries, as needed.

I understand that this authorization will remain its effectivity until I provide written notice of revocation to the health care facility. I do hereby consent and give authority to the health care facility to release information to my employer and process my billing on my behalf whenever applicable.

I have read or have had explained to me the information about influenza and influenza vaccine. I have had an opportunity to discuss the benefits and risks of influenza vaccine with a healthcare provider of my choice before coming here today. I have had a chance to ask questions which were answered to my satisfaction.

I understand the benefits and risks of influenza vaccine and request that the vaccine be given to

Your Name

First NameLast Name

Date of Birth

Date

Age

Your Child's Name

First NameLast Name

Your Child's Date of Birth

Date

Age

Does the person receiving the vaccine have any history of severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken feathers?

Does the person receiving the vaccine have a history of Guillain-Barré syndrome or a persistent neurological illness?

Has the person received a live vaccine within the past 30 days?

Does the person receiving the vaccine has ever had a severe allergic reaction to flu vaccine or any other vaccine or vaccine components?

Is the person receiving the vaccine pregnant?

Name of Parent or Person Receiving Vaccine

First NameLast Name

Signature

Date Signed

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.